Urogynae and Menopause Flashcards
Stress incontinence surgical management:
Urethral bulking agents
• Benefits – no incision, low risk, best for intrinsic sphincter deficiency,
• Risks – highest recurrence, need for repeat, urethral injury, need for self catheterisation
Transvaginal mid urethral tape
• Benefits – gold standard for SUI with 90% success rates
• Risks – infection, bleeding, bowel/ureteric injury, de novo detrusor overactivity, voiding dysfunction, dyspareunia, chronic UTI, mesh erosion, fistula, thigh pain (transobturator only)
Burch colposuspension (the bladder neck is lifted, vagina is attached to the ligament behind the pubic bone with sutures and this will lift and support your bladder neck which helps it resist increases in abdominal pressure)
• Benefits – avoid further vaginal incision, good continence rates (90% at one year, 70% at 5 years), no mesh risks
• Risks – as above without mesh risks, risk of posterior vaginal wall prolapse due to angulation of vagina.
Pelvic organ prolapse management:
o Lifestyle advice
avoid heavy lifting
avoid straining (give laxitives)
weight loss
o Conservative
pelvic floor muscle physiotherapy – may improve symptoms or early stage prolapse but does not alter prolapse severity
Ovestin cream for vulvovaginal atrophy and dyspareunia
Offer pessary
• Type - ring for anterior prolapse, space occupying (shelf or cube) for vault prolapse
• Risks include erosion, infection, discomfort, failure.
o Surgical options
Anterior repair + SSF
Abdominal (laparoscopic or open) sacrocolpopexy/hystopexy
Colpocleisis not appropriate given patient wants to continue having intercourse
Overactive bladder management:
Conservative – avoid bladder irritants, 1.5L fluid balance, bladder retraining, biofeedback
Medical
• Anticholinergics - oxybutynin or solifenacin – side effects include dry eyes/mouth, constipation, long term risk of dementia. Aim for short term use only.
• B3 adrenoceptor agonist - Mirabigron – can cause hypertension, renal and liver impairment
Electrical
• No routinely recommended
• TENS/PTNS - offer last resort
Surgical – botox, clam cystoplasty, detrusor myomectomy, ileal conduit
Anterior Repair Steps:
• Consent
o Bleeding
o Infection
o Damage to bladder
o Dysparunia, vaginal narrowing
o Recurrence
o Voiding dysfunction
o Buttock ache
• Steps of Anterior Repair
o Pre-Op
Consent
Anaesthetic assessment
WHO sign in
o Intra op
Anaesthetic
Position in dorsal lithotomy
Check allergies and antibiotics (not routinely required)
VTE prophylaxis
Prep and drape
WHO Time Out
Do not place IDC at start of procedure
EUA to reassess POP-Q score now fully relaxed with anaethetic
Place Allis forcep on anterior vaginal wall in the midline 1-2cm from urethral meatus
Place second Allis forcep on the anterior vaginal wall in the midline as proximal as possible beyond the most distal portion of the prolapse
Assistance to hold allis forceps superior and inferiorly to put vaginal mucosa under tension
Infiltrate local anaesthetic in the midline to elevate mucosa off underlying fascia and extend infiltration laterally on each side
Use scalpel to cut vaginal mucosa longitudinally between each allis forcep
Place new allis forceps on free edge of vaginal mucosa on one side to elevate it off the fascia. Dissect the mucosa off the fascia (can be blunt with small gauze wrapped over a finger if no previous surgery or may need to be blunt with fine tissue forceps angled towards the mucosa). Repeat on opposite side until paravaginal fasica is reached.
Plicate the fascia using interrupted 2.0 pDS leaving each suture untied and long and attached to a small artery clamp
Sequentially tie off each suture starting with most proximal in the vagina.
Ensure haemostasis
Assess need to trim vaginal mucosa. Do not perform excessively to avoid undue tensions on repair increasing risk of breakdown and vaginal narrowing
Repair vaginal mucosa continuously with 2.0 vicryl
IDC + pack
o Postop
Document
discuss follow-up: analgesia, pelvic rest 4-6 weeks, ovestin cream, no heavy lifting 4-6 weeks, clinic 4-6 weeks
Bioidentical Creams for menopause
● Bioideinticals and compounded creams not recommended as no evidence to prove efficacy, other preparations have sound clinical evidence. Also as not commercially prepared have varying levels of active hormone.
● Needs oestrogen + progesterone for endometrial protection
● No CI to HRT in history
● Can take HRT up to 10y and <60 in general with minimal risk
● Appears to have a cardiovascular benefit in younger women at least for first year, though NOT indicated for prevention
● Options for treatment
o COCP eg Ava 20
o E2 with cyclical progesterone (CEE or E2 or patch with MPA or micronized PG or mirena)
o If problems with PG Sx might try continuous
● May have bloating/breast pain
● May have resumption of Sx on stopping
● Written information
When to use mesh in urogynae:
Not supported as first line
MDT approach
Fully inform woman risk of chronic pain associated = 1-3% Mesh erosion = 2% Permeant structure may be difficult to remove.
Submit case for clinical audit purpose
Refer appropriately trained sub specialist urogynaecologist
Colpocleisis:
An obliterative procedure done vaginally to support pelvic organs
Success >90%
Quick procedure and recovery
Can be done under local anaesthetic if required
~30% stress urinary incontinence following procedure
No longer sexually active
Cervix and endometrium no longer accessible screen pre-op
Posterior repair:
reinforce the weaken layers between the rectum and vagina Success rates 80-100% Constipation Dysparunia Injury to rectum Vaginal shortening Pudendal neurology Don’t recommend pregnancy post
Anterior repair:
reinforce the weakened layers between the bladder and vagina
Increased rate of recurrence if uterus preserved
Future pregnancy not recommended
0.5-2% injury to adjacent structures
Risk of retention, UTI, de novo stress/urge incontinence
Risk of dysparunia
Urogynae & POP exam and initial investigations:
POP-Q Urine dip and MSU Post void residual Urodynamics (not if pure stress) Pelvic floor muscle tone Measure genital hiatus and perineal length Q tip test for urethral hypermobility Elicit stress symptoms with cough test Bladder diary
Management of POP conservative:
Weight loss Smoking cessation Treat constipation Avoid heavy lifting >5kg Pelvic floor muscle training improvement of symptoms at 6 months 10 contractions TDS holding 5secs Topical oestrogen Pessary
Vaginal hysterectomy and vault suspension:
~85% success rate
Faster return to normal activity and less complications vs open and lap
~10% vault heamotoma, infection, UTI
2% risk damage to surrounding structures
40-45% de novo incontinence
Risk of fistula
Abdominal sacrocolpopexy/ lap approach:
success 76-100% 4.1% reoperation rate Lower rate prolapse recurrence vs SSF Reduced dysparunia Less post op SUI Longer recovery, operating time compared to vaginal routes
Sacrospinous fixation:
Success 67-97% Recurrence 2-19% Post op buttock pain De novo SUI Pudendal nerve injury (vaginal pain, problems with bowel and blader) Sciatic nerve irritation Increase anterior compartment prolapse recurrence Temporary ureteral obstruction
Pessary fitting:
With chaperone and consent:
• Empty bladder
• Dorsal litotomy
• Pelvic examination:
o Skin condition – rashes, postmenopausal changes\
• POP_Q:
o Introitus (gaping)
o Perineal body
o Descent with valsalva – perineum supported or not, anterior/posterior/vault/uterine prolapse
o SIMS speculum in left lateral assessing extent of descent and locaitons
• Decide which pessary most suitable – ring/shelf/sub-urethral support/gelhorn/cube
• Bimanual
o Masses, descent, approximate length from posterior fornix to posterior aspect symphasis pubis
• Select pessary size
• Ovestin
• Ring: Fold pessary in half
• Gently part labia
• Insert pessary, curve DOWN
• Fit behind symphisis
Stand woman up, ask her to squat a few times
If comfortable – can get dressed
Have water/cup of tea in waiting room, make sure can pass urine and walk around comfortably
Review 3 months unless problems earlier (pain/bleeding/expulsion/unable to PU/new incontinence)